Acute myocardial infarction is a final manifestation of inadequate blood supply and thus oxygenation of cardiac tissues. It is preceded by significant risk factors which include smoking, obesity, diabetes, hypertension, dyslipidemias and genetic predisposition. These factors lead to an atherosclerotic process resulting in stenosis of coronary artery lumen. With time, these plaque is disrupted, and it leads to the activation of the clotting cascade. The formed clot cuts blood supply to the distal tissues and thus ischemia and subsequent necrosis. Necrotic cardiac muscles trigger a fibrotic response that in turn may trigger fatal arrhythmias such as ventricular and atrial fibrillations. This may end up causing sudden cardiac death.
Differential diagnoses
Pericarditis- Though the patient doesn't have the classic symptoms of pain on deep inspiration, this is still in keeping with Pericarditis because of the localization of the pain.
Pulmonary embolism is also high in the list following disruption of an atherosclerotic plaque and its travel to the lungs.
Angina pectoris as a primary symptom of myocardial infarction.
PLAN
Diagnostic Tests
Troponin blood levels are used to assess the extent of myocardial tissue destruction (Gimenez et al., 2013).
ECG- Confirms an ST-elevation or depression MI and abnormal Q waves. This could be both diagnostic and as a follow up during management.
Coronary angiography to assess its patency.
Screening
A routine lipid profile should be done to evaluate the preponderance to future myocardial infarction and possible complications of the current situation.
An annual ECG will be necessary to assess the integrity of the heart valves. This could be done at the same time with a coronary angiography.
Treatment and management of MI.
- The patient should take 75 mg of aspirin daily to aid in reducing tendencies of thrombosis by blocking TXA formation through inhibition of prostaglandin endoperoxide synthase (Simes et al., 2014).
- Nitrates such as nitroglycerin 0.5 mg once daily are also recommended to aid in vasodilation hence increasing blood supply to the cardiac muscles and decreasing the severity of angina (Steinhorn, Loscalzo & Michel, 2015).
- Analgesics such as ibuprofen 300 mg three times should also be prescribed for oral administration to help in the management of chest pain.
- Supplemental oxygen to relieve shortness of breath and improve tissue perfusion.
- Thrombolytic agents like streptokinase (1.5 International Units, IU) can be given intravenously to help in digesting the clot and thus maintaining coronary artery patency.
Education
Advice on lifestyle modification, diet, exercises and emphasize on immediate consult of a doctor in case the patient develops similar presenting symptoms. Schartum-Hansen et al., (2015) affirm that implementation of lifestyle changes is one of the most significant steps for preventing angina. Therefore, the patient should be enlightened on why it is necessary for him to cease smoking or taking excessive alcohol that is if he smokes or drinks. Additionally, the patient will be encouraged to eat a healthy diet with limited amount of saturated fat and lots of fruits, whole grains, and vegetables (Massera et al., 2015). If he is overweight, he should engage in exercises that reduce his weight. However, physicians should warn the patient that he should avoid extreme physical activities or exercises which can easily precipitate angina. Education should also shed light on why it is essential for the patient to relax and avoid large meals that make him feel full.
Consult/Referrals
The patient will be referred to a nutritionist to help advise the patient about diet. He will also be referred to community cardiology associations where he can share stories with patients suffering from similar problems and learn more from them.
Follow-up
Close follow-up will ensure that our patient improves clinically. The patient will be requested to visit the clinic at least once after every three weeks for check-up purposes. He will be given a hotline number always to call whenever he has a question or has an attack.
References.
Gimenez, M. R., Hoeller, R., Reichlin, T., Zellweger, C., Twerenbold, R., Reiter, M., ... & Meller, B. (2013). Rapid rule out of acute myocardial infarction using undetectable levels of high-sensitivity cardiac troponin. International journal of cardiology, 168(4), 3896-3901.
Massera, D., Zaman, T., Farren, G. E., & Ostfeld, R. J. (2015). A Whole-Food Plant-Based Diet Reversed Angina without Medications or Procedures. Case reports in Cardiology, 2015.
Schartum-Hansen, H., Pedersen, E. R., Svingen, G. F., Ueland, P. M., Seifert, R., Ebbing, M., ... & Nygard, O. (2015). Plasma choline, smoking, and long-term prognosis in patients with stable angina pectoris. European journal of preventive cardiology, 22(5), 606-614.
Simes, J., Becattini, C., Agnelli, G., Eikelboom, J. W., Kirby, A. C., Mister, R., ... & Brighton, T. A. (2014). Aspirin for the prevention of recurrent venous thromboembolism: the INSPIRE collaboration. Circulation, CIRCULATIONAHA-114.
Steinhorn, B. S., Loscalzo, J., & Michel, T. (2015). Nitroglycerin and nitric oxidea rondo of themes in cardiovascular therapeutics. New England Journal of Medicine, 373(3), 277-280.
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